The Ultimate Pediatric Billing Guide for Busy Practices

Before You Start: The Hidden Impact of Billing Inefficiencies

Running a pediatric practice is incredibly rewarding—but when billing inefficiencies pile up, they can quietly eat away at your revenue, strain your staff, and slow down your growth. Pediatric billing comes with its own set of challenges: complex coding, frequent insurance changes, and time-consuming denial management. According to industry estimates, up to 80% of medical bills contain errors, and unresolved denials can reduce net revenue by over 5%.

At Altus Pediatric Billing, we specialize in helping pediatric practices streamline operations, improve claim accuracy, and strengthen profitability. We’ve seen firsthand how outdated systems and inconsistent billing processes lead to revenue leaks—often without the practice realizing it.

But it doesn’t have to be this way.

With the right pediatric billing services in place, your practice can reduce claim write-offs, speed up collections, and improve your overall financial health—without working longer hours or hiring more staff. This guide will walk you through key strategies that make a difference: identifying billing errors, tracking the right KPIs, strengthening front-desk workflows, denial resolution, and optimizing your fee schedule.

Along the way, we’ll highlight how partnering with a pediatric-specific medical billing team like Altus can transform your revenue cycle. From our zero-write-off policy to our 30-point profitability review, everything we do is designed to help pediatric practices operate more efficiently and collect every dollar they earn.

Let’s dive in—and make sure your practice is equipped to thrive.

Stop Losing Revenue: Fix These Pediatric Billing Mistakes

Every dollar counts in a pediatric practice – yet many clinics lose revenue due to avoidable billing mistakes. These errors may seem minor day-to-day, but they add up fast. For example, nearly 20% of all claims are denied and as many as 60% of those denied claims are never resubmitted​, meaning lost income you should have collected. To keep your practice financially healthy, it’s critical to spot and fix these mistakes. Below are some of the most common pediatric billing mistakes that drain revenue, along with tips to address them:

Missing or Unbilled Services

In a fast-paced pediatric office, it’s easy to miss charges. A vaccine may be given but never billed, or a minor procedure might not make it to the charge sheet. These oversights mean revenue is left on the table.

Fix: Use your EHR to generate a daily list of documented services, then cross-check it against submitted charges. A simple end-of-day checklist can catch missed items before claims go out. Periodic chart audits also help ensure every vaccine, screening, and procedure is properly billed.

Coding Errors and Missing Modifiers

Pediatric coding can be tricky. Using the wrong CPT code or forgetting modifiers—like missing a -25

 when billing a sick visit with a well visit—can lead to denials or reduced payments.

Fix: Train staff regularly on pediatric-specific coding. Provide a cheat sheet with common coding scenarios (e.g., well visits with immunizations). Use claim-scrubbing software that flags mismatches or missing modifiers before claims are submitted.

Not Verifying Insurance Eligibility

Coverage changes frequently—especially for newborns or when parents switch jobs. If insurance isn’t verified at each visit, claims may be denied and deadlines missed.

Fix: Train front-desk staff to verify insurance at every check-in, or use an automated eligibility system. Confirm referrals and authorizations are in place before the visit to avoid denials.

Missing Timely Filing Deadlines

Claims must be submitted within payer-specific timeframes—often 90 days for private payers or up to a year for Medicaid. Delays in submission or follow-up can result in lost revenue.

Fix: Submit claims daily or within 48 hours of the visit. Use A/R aging reports to flag claims nearing deadlines. Set internal alerts for claims at 60, 90, or 120 days (based on payer rules). At Altus, we use a 30-point checklist to ensure no claim falls through the cracks.

Not Following Up on Denials

Many denied claims are never worked—often due to overwhelmed staff or unclear processes. Writing them off means giving up money your practice is owed.

Fix: Create a denial management process. Review every Explanation of Benefits (EOB) with a denial or partial payment. Correct and resubmit claims with fixable errors. For clinical denials, appeal with supporting documentation. Consider assigning a dedicated biller or outsourcing denial follow-up. At Altus, we enforce a “zero claim write-off” policy and pursue every claim until resolution.

By addressing the mistakes above, pediatric practices can recapture significant revenue that might otherwise be lost. Even small improvements – like catching a few missed charges a week or appealing denials you used to write off – can yield tens of thousands of dollars in a year for a moderately busy practice. More importantly, fixing these issues builds a stronger billing foundation for everything else. 

Essential Billing Metrics Every Pediatric Practice Needs

To manage and improve your billing performance, you first need to measure it. Tracking the right metrics gives you visibility into where your revenue cycle is healthy and where it needs work. Many busy pediatric practices only look at the bank balance or monthly revenue, but digging into a few key billing metrics (KPIs) can uncover hidden issues and guide smarter decisions. Here are the essential billing metrics every pediatric practice should monitor:

• Days in Accounts Receivable (A/R): This measures how quickly you collect payments after services are rendered. It’s essentially the average number of days it takes for your claims to get paid. A lower number means faster cash flow. 
  • Benchmark: Aim for around 30 days or less in A/R​. Pediatric practices often have many small claims, but that’s more reason to collect promptly. If your Days in A/R is creeping up (say 45, 60, 90 days), it signals delays in billing or collections. You might have lots of pending insurance claims or patient balances aging out. Tracking this metric month over month helps you see if improvements (like faster claim submission or better follow-up) are working.

• Percentage of A/R over 90 days: Not all receivables are equal – money owed for 120 days is far less likely to be collected than money owed for 30 days. This metric looks at what portion of your accounts receivable is aging beyond 90 days (or you can track 120 days as well). A low percentage is good, as it means most of your money is coming in on time. 
  • Benchmark: Keep A/R over 90 days to 15% or less of your total A/R. If you find that, say, 30% of your receivables are very old, it’s a red flag that many claims or patient bills are not being attended to. Common causes might be unresolved denials, patients on payment plans (or not paying), or backlogged claims. By monitoring this, you can set goals like “we will reduce >90-day A/R to under 10% by next quarter” and then implement tactics (aggressive follow-up on old claims, collection calls on patient balances, etc.).

• Claim Denial Rate: This is the percentage of submitted claims that come back denied initially. It directly reflects your billing accuracy and front-end processes. 
  • Benchmark: Industry-wide, an acceptable range is often cited around 5–10% denial rate, but truly high-performing practices target under 5%. If your denial rate is, say, 15%, you have significant room for improvement. Each denial means extra work and delayed or lost revenue. Tracking denial rate over time – and by payer or by reason – will help you pinpoint issues (for example, if one insurance company is denying 25% of claims, you might investigate if their claims requirements have a quirk). We will discuss how to reduce denials in the next section. The key is to measure it: you can’t lower your denial rate if you aren’t aware of how high it is.

• Clean Claims Rate (First-Pass Acceptance Rate): Opposite of denial rate, this metric tells you what percentage of your claims get paid without any denial or correction. It’s a good indicator of how error-free your claims are on submission. A high clean-claim rate means your coding and billing info is accurate up front, leading to faster payments. 
  • Benchmark: The Healthcare Financial Management Association (HFMA) recommends aiming for a 98% clean claim rate. In practice, that means 98 out of 100 claims get through the insurer’s system without needing fixes. If your clean rate is 85%, that implies 15% of claims had some issue (missing info, coding error, etc.) – an area to improve. Even moving from, say, 90% to 95% can save a ton of staff time and accelerate cash flow. Use tools like your clearinghouse reports to track this metric.

• Net Collection Rate (Adjusted Collection Rate): This is one of the most telling metrics for overall billing performance. It measures how much of the money you should have collected (after write-offs like contracted discounts) you actually collected. In formula terms: payments / (charges – contractual adjustments) over a period, expressed as a percentage. Net collection rate essentially asks: Of the revenue that was legitimately collectible (i.e., not written off per insurance contracts), what percent did we collect? 
  • Benchmark: 95% or higher. MGMA data shows high-performing practices often achieve 95-99% net collection. If yours is, say, 85%, that means you’re only collecting 85 cents of every dollar you could be – indicating significant lost revenue. Causes for a low net collection could be uncollected patient balances, unappealed denials, or not billing secondary insurances, etc. By monitoring this, you see the end-result of all your billing processes combined. Improving other metrics (denials, patient collections) will drive this number up. Many practices find this KPI eye-opening when they calculate it for the first time.

• Average reimbursement per visit (or per encounter): This metric can be useful to track the financial yield of your visits and see trends over time. Pediatric practices might use this to see if changes in coding or payer mix affect revenue. For instance, if you implement better coding for developmental screenings or vaccine admin fees, you might see your average revenue per patient visit increase. It can be skewed by visit types (a month with more sick visits vs well-child checks will differ), but over a year it can show whether you are monetizing your services appropriately. If you have data to compare to benchmarks (e.g., from networks or peers), it’s even more useful. 
  • Benchmark: Varies widely, but you can track your own baseline and aim to improve it with optimized billing.

• Patient collection rate: In pediatrics, a lot of revenue is insurance-based, but patient balances (copays, deductibles, non-covered services) are increasingly important. This metric measures what percentage of patient-responsible dollars you collect. For example, if in a month patients owed a total of $5,000 (copays, coinsurance, etc.) and you collected $4,000 of it, your patient collection rate is 80%. 
  • Benchmark: The closer to 100% the better, but realistically, anything above 90% is strong. If this rate is low, it points to issues in collecting co-pays at visits or effectively billing patients. (One sobering fact: providers on average only collect about 50-70% of balances after a patient leaves the office​, so it’s critical to collect upfront when possible.)

These metrics should be reviewed regularly – at least monthly – and discussed in your management meetings. Many pediatric billing services (including Altus) provide monthly reports with key practice metrics and benchmarks for this reason​. Seeing your performance in black-and-white numbers can illuminate problems that weren’t obvious. For instance, you might discover your denial rate spiked in the last two months (maybe after a new coding guideline took effect) or that your A/R >90 days is creeping up (indicating lagging follow-ups).

By knowing your numbers, you can set concrete targets: “We will cut our denial rate from 10% to 5% in six months,” or “Let’s get Days in A/R down to 30.” Then, implement process changes and watch the metrics to see if they respond. It turns billing from a source of stress into a manageable, data-driven process. (In a forthcoming article on Pediatric Practice Billing Metrics, we’ll dive deeper into how to calculate these KPIs and share benchmark data specific to pediatrics. Be sure to check that out for a deeper analysis on using metrics to drive financial health.)

How Billing Errors Hurt Your Practice & How to Prevent Them

No one likes to admit it, but billing errors happen – a lot. We’re all human, and the medical billing process has many steps where mistakes can creep in. The impact of those errors, however, can be far-reaching. Let’s examine how billing errors (big and small) hurt your practice, and more importantly, how to prevent them.

First, consider the scope of the problem: the vast majority of medical bills have errors of some kind. Surveys of billing advocates found that up to 80% of medical bills contain errors. While that statistic often includes hospital billing, even in office practice billing the error rate is significant. Each error – whether it’s a wrong code, a misspelled patient name, or an incorrect unit count – can trigger a domino effect: claim denials, payment delays, rework, resubmission, or incorrect patient charges. This not only hurts your bottom line but can also damage patient trust and waste valuable staff time.

How Billing Errors Hurt Your Practice

Lost or Delayed Revenue

This is the most obvious impact. A simple billing mistake—like a missing modifier or wrong CPT code—can cause a claim to be denied or underpaid. If it’s not caught, you may lose that money completely. Even if it is corrected, payment can be delayed by weeks or months.

Example: A mis-coded visit might result in a $0 payment until fixed. If 10% of your monthly claims have issues like this, your cash flow could be taking a major hit. And since nearly 60% of denied claims are never resubmitted, that’s money left behind for good.

Higher Operational Costs

Every billing error takes time to fix—and time is money. Reworking a denied claim costs an average of $25 per error in staff effort. Multiply that by dozens of errors a week, and the costs add up quickly.

Your staff ends up doing the same work twice instead of focusing on growing the practice or helping patients. It’s like having a leak in your operations—slow and expensive.

Staff Burnout and Low Morale

When billing mistakes keep happening, your team feels it. Billers and office managers get stuck in reactive mode, constantly fixing issues instead of moving the practice forward.

Clinicians also feel the pressure when revenue drops or claims keep bouncing back. It can lead to stress, tension between teams, or even burnout. A smooth billing system gives everyone space to focus on what they do best.

 Frustrated Patients

Billing errors don’t just stay in the back office—they reach your patients too. A coding mistake can lead to a wrong or confusing bill.

Imagine a parent receiving a $200 charge for a covered vaccine. They call upset, your staff scrambles to explain or rebill, and the family loses trust in your office. Repeated issues like this can hurt your reputation and drive patients away—especially in today’s review-driven world.

Compliance and Audit Risks

Even honest mistakes can raise red flags with payers or auditors. If the same error (like billing a higher-level service code) keeps happening, it might be seen as suspicious—even if unintentional.

Correcting errors early helps protect your practice from audits, fines, or accusations of improper billing. It also shows that your billing process is ethical, accurate, and audit-ready.

Best Practices to Prevent Billing Errors and Improve Accuracy

Given these consequences, error prevention should be a top priority. Here are strategies to minimize billing errors in your pediatric practice:

1. Build Checks and Balances Into Your Workflow

Avoid having just one person handle the entire billing process. Even experienced staff can miss things without a second set of eyes.

• Tip: Have one person enter charges and another review high-value claims or a daily sample before submission.
• Use your billing software’s edit reports to flag missing data, invalid codes, or mismatched diagnoses.
• Set a rule: all claims over a certain amount (or procedure type) get a manual review.
• Make sure alerts in your EHR or clearinghouse are turned on—and reviewed daily.

 

2. Use Smart Billing Technology

Outdated software is a hidden risk. If your system doesn’t include the latest ICD-10 or CPT codes, claims may be rejected.

• Use modern billing systems that update codes regularly.
• Consider a claims scrubber tool if you process a high volume—it checks claims against thousands of rules pre-submission.
• Scrubbers can confirm age-specific coding, required modifiers, payer-specific fields, and more.

At Altus, we use a 30-point checklist built into our technology stack to catch issues before they reach payers.

3. Make Ongoing Education a Priority

Billing rules change constantly. Vaccine codes, E/M guidelines, and payer policies all evolve—your staff needs to stay current.

• Encourage regular training and certification updates for billers and coders.
• Subscribe to pediatric coding newsletters or join AAP/AAPC workshops.
• Share new payer requirements in quick team huddles.
• If you don’t have an in-house expert, bring in a pediatric coding consultant for periodic check-ins.

4. Standardize Documentation Practices

Many billing errors stem from poor documentation. If it’s not clearly recorded, it may not be billed correctly—or at all.

• Work with providers to standardize charting.
• Use EHR templates for common visits to prompt all billable items.
• Make sure all visits are closed with proper diagnoses and procedures logged.

Strong documentation makes accurate billing faster and easier.

5. Consider Outside Support

 If your team is overwhelmed or billing errors are frequent, it might be time to get help.

• Outsourcing to a pediatric-focused billing partner can reduce errors and increase collections.
• These partners bring specialized knowledge, proactive denial management, and up-to-date compliance insights.
• Not ready to outsource? Hire a revenue cycle consultant to audit your current workflow and provide feedback.

At Altus Pediatric Billing, we began as a consulting firm, and we still audit many practices to help uncover hidden inefficiencies and revenue gaps.

6. Standardize Your Billing Process and Track Errors

Every team member should follow the same steps from check-in to claim submission.

Create a written SOP (standard operating procedure) for billing.

• Keep an error log or dashboard—track what went wrong, how it was fixed, and how to prevent it going forward.
• Use the log to identify trends and create training plans or process improvements.

7. Foster a Culture of Accuracy—Not Blame

When your team feels safe reporting mistakes, you catch and fix them faster.

• Encourage staff to report issues without fear of blame.
• Focus on the process: “What slipped through, and how can we fix the workflow?”
• Celebrate wins like “error-free” weeks or successful appeals.

The result: a collaborative, high-performing billing team that learns and improves together.

By dramatically reducing billing errors, your practice will see faster payments, fewer denials, and lower stress overall. It may take some effort to revamp processes and train staff, but it pays off. Imagine having confidence that each claim going out the door is 98% likely to get paid without a hiccup – that’s achievable and many practices do reach that level of performance (98% clean claims). Plus, a reputation for accurate billing and clear communication becomes a selling point to patients and a relief to your administrative team.

Denied Claims? How to Fix and Prevent Pediatric Denials

Even with a great process, claim denials are a fact of life in medical billing. Some claims will be denied by insurers for various reasons. However, the difference between a struggling practice and a thriving one is how you handle denials. If ignored, denied claims will hurt your finances badly – but if managed well, many can be fixed and paid, and future denials can be prevented. Let’s talk about strategies to fix denials when they occur and prevent as many as possible, especially focusing on issues common in pediatrics.

Understand the denial landscape: First, quantify and categorize your denials. As mentioned in Metrics, track your denial rate. Industry surveys show an overall rise in claim denials, with average rates reaching 10% or more in recent years. For private payers, roughly 15% of claims are initially denied on submission​. That’s a significant portion of your claims. The top reasons for denials in medical practices (per MGMA data) include lack of prior authorization, missing/incorrect information, not meeting medical necessity, non-covered services, out-of-network provider, duplicate claims, and coordination of benefits issues. In a pediatric context, some specific denial triggers we often see are:

• No prior authorization – e.g. for specialist referrals or ADHD evaluations if required by certain plans.

• Incomplete information – e.g. child’s insurance had updated and the new ID wasn’t used, or a secondary insurance info missing (common with divorced parents both covering a child).

• Service not covered – e.g. a vaccine not covered by a particular plan (though vaccines are usually covered, some plans might deny certain brand vaccines if out of network labs were used for administration, etc.), or limit on well-child visits (some plans might deny a well visit as “frequency limit exceeded” if done too soon).

• Medical necessity denials – not very common for typical pediatric E/M visits, but could occur for things like certain therapies or off-label medication uses.

• Coding bundling issues – e.g. a sick visit denied because it wasn’t billed with modifier -25 alongside a well visit (the system saw it as duplicate/included service).

• Coordination of benefits – if the child has dual coverage, claims might deny until coordination is sorted (e.g. which insurance is primary). This is common if, say, both parents have insurance covering the child.

Knowing the patterns in your denials is key. Pull reports: what percentage of denials are for authorization vs coding vs patient not eligible, etc. This helps target your fixes.

How to Fix Denied Claims (Effective Denial Management):

1. Act quickly and consistently: The moment a denial comes in (whether via paper EOB or electronic remit), it should be logged and worked. Set a policy that all denial or discrepancy codes are addressed within X days. The sooner you address it, the higher the chance of recovery (and you stay within appeal filing deadlines). Don’t let denial paperwork pile up in a drawer – by the time you get to it, it might be too late. Many practices do a weekly denial review meeting or assign a specific day for denial catch-up to ensure none get missed.

2. Identify the reason and gather information: Always read the denial code/reason provided by the payer. It could be explicit (“Patient not covered on date of service” or “Procedure requires prior authorization”) or cryptic (some code like CO-197). Use your resources: payer portals often have more info, and remittance codes can be looked up. Once you know why it was denied, gather what’s needed to correct it. This could mean checking the patient’s insurance info, pulling the medical records, or calling the insurance for clarification. For example, if a claim was denied for missing referral, can you obtain a retroactive referral? If it’s denied for missing info, figure out what info (sometimes a claim might miss the newborn’s Medicaid ID, etc.).

3. Correct and resubmit (or appeal): If the denial reason indicates something fixable on the claim, correct it and resubmit as a corrected claim. For instance, if the claim had a wrong insurance ID, fix the ID and resend. If a modifier was omitted, add it and resend. Many payers allow resubmission of corrected claims electronically within the timely period. If the denial requires an appeal (usually for things like medical necessity or authorization issues), prepare a formal appeal letter. In an appeal, be concise but include supporting documentation: the medical notes, a letter explaining why the service was necessary (cite the patient’s condition or standard of care guidelines), etc. Also cite the payer’s own policy if you have it (e.g., “Per XYZ Insurance policy #123, this service is covered for diagnosis ABC, which this patient has, as documented.”). Send appeals with tracking if via mail, or through the payer’s portal if available. Keep copies of everything.

4. Follow up on the follow-up: Don’t assume a resubmitted claim or appeal will automatically get processed. Calendar a follow-up. For example, if you appeal a claim, mark 30 days out to check if it’s been paid or at least received. If not, call the payer to check status. Persistence is key – payers often bank on providers giving up. One study noted that providers eventually overturn 54% of appealed denials​, but that only happens if you actually pursue them. If an appeal is denied again and you still believe it’s wrong, some insurers allow a second-level appeal or even a peer-to-peer review for medical necessity cases. Decide how far to go based on the dollar value and principle involved.

5. Communicate with patients as needed: Sometimes a denial will ultimately result in patient responsibility (for example, if the service truly isn’t covered, like a travel vaccine or after insurance termination). In those cases, communicate promptly and professionally with the family. It’s better for them to know early that “insurance didn’t pay for this, so you’ll be billed $X” rather than getting a surprise bill many months later. Often, a quick call to explain the situation and any options (e.g., payment plan, or asking the family to call the insurer as well to contest a denial from their side) can go a long way in maintaining goodwill.

Preventing Pediatric Denials in the First Place

Secure Prior Authorizations Early

Pediatric services like psychological testing for ADHD, high-cost injectables, MRIs, and specialist referrals often require pre-authorization—especially under HMO plans.

Train staff to check requirements when scheduling. If prior auth is missing, reschedule the service if possible. Document auth numbers directly on the claim to avoid rejections.

Verify Insurance and Eligibility at Every Visit

Simple errors—like outdated member IDs or inactive policies—are among the most common and preventable causes of denial.

Use your clearinghouse or payer websites to confirm insurance details before each appointment. Also, ask families annually about changes to insurance, and make sure your billing system reflects the correct primary and secondary coverage.

Submit Clean, Accurate Claims

High clean claim rates = fewer denials. Use claim scrubbers or rule-based edits in your billing software to catch issues before submission.

Examples include flagging sick and well visits on the same day without a -25 modifier, incorrect age-based CPT codes, or missing provider credentials. Make sure all providers are credentialed and linked correctly to payers in your system.

At Altus Pediatric Billing, we apply a detailed 30-point checklist to every claim before it’s submitted—so nothing slips through the cracks.

Stay Ahead of Coding and Payer Policy Changes

Payers often update their rules—sometimes without much notice. One might start bundling developmental screenings unless modifier -59 is added, for example.

Stay informed by subscribing to payer bulletins, following AAP coding updates, and joining pediatric billing webinars. Networking with other practices also helps—many denials can be avoided by sharing real-world experiences.

Altus hosts monthly peer groups for pediatric clients to compare notes on denials, payer quirks, and policy changes—turning shared knowledge into fewer billing surprises.

Track and Address Recurring Denials

Look for trends in your denial reports. Are well visits getting denied for “exceeded frequency”? Tighten your scheduling protocols.

Do vaccine codes keep getting rejected? Review your payer contracts or check if they should be billed to VFC or your state program.

Every pattern points to a process that needs refining. Build fixes into your training, edits, or payer outreach strategy.

Embrace a Zero-Tolerance Mindset for Avoidable Denials

Make low denial rates a team goal—aim for under 5% and track progress in staff meetings or dashboards.

Celebrate wins and dig into spikes to find root causes. Often, just measuring denial rates increases awareness and accountability.

At Altus, our billing specialists don’t stop until every claim is paid. That persistence—backed by experience and process—dramatically reduces write-offs and accelerates cash flow.

In summary, fixing denials is about being prompt, methodical, and persistent; preventing denials is about tightening up your front-end processes and staying informed. A pediatric practice that masters denial management will see significant improvements in cash flow. You’ll go from chasing your tail on unpaid claims to actually closing the loop on them systematically. It’s not unrealistic to recover the majority of initially denied dollars – remember, two-thirds of rejected claims are recoverable with the right strategy. And each prevention is time saved for your staff and quicker payment.

How Better Billing Can Help Your Front Desk Run Smoother

When we think about billing, we often focus on back-office processes. But billing has a huge impact on your front desk and overall office workflow. Front-desk staff are the first and last touchpoint for patients in your practice, and they handle everything from scheduling to collecting copays and answering billing questions. Inefficient billing can create chaos for them, while streamlined billing can make their job much easier and improve the patient experience. Let’s explore how improving your billing processes will lighten the load on your front desk and lead to a smoother-running practice.

Front desk as the first line of billing: In many ways, the revenue cycle starts and ends at the front desk. This is where patient information is taken, insurance is checked, and payments are initiated. If this foundation is shaky, your billing will suffer down the line. Conversely, if your front desk is empowered with good billing practices, many problems never occur. For example, a well-trained front desk that verifies insurance and explains patient financial responsibility can prevent surprises later (no angry calls about “I didn’t know I owed that”). As one practice management advisor put it, “A little time and effort at the front desk can save a lot of time and money when it comes to billing and collections.”​ That means tasks done correctly at check-in/checkout can preempt costly rework.

Clear Copay and Balance Collection at Check-In

One common challenge at the front desk is knowing exactly what to collect during a patient visit.

When billing is organized, the system reflects real-time balances. Staff can clearly see:

• “$20 copay for today, plus $15 from a previous visit. Please collect $35.”

This clarity empowers your team to confidently collect what’s owed—on the spot. And that matters: after a patient leaves, collection rates drop significantly (to 50–70%).

Fewer Patient Calls and Billing Disputes

Billing errors often trigger follow-up calls like:

• “Why did I get this bill?”
  “Did my insurance cover the lab work?”

These questions slow down the front desk and take time away from other duties.

Clean billing and clear statements reduce confusion and prevent unnecessary calls. If a question does arise, strong documentation helps staff give a fast, accurate answer.

At Altus, we log detailed notes in each patient’s billing account, so your team can say:

• “Claim denied—appeal submitted. Statement sent May 1 for $25 copay.”
  This level of transparency makes a huge difference.

Smoother Patient Flow at Check-In and Check-Out

When your billing system is synced with front-desk workflows, the entire patient experience improves.

If eligibility checks are done 48 hours in advance (automatically or manually), staff already know if there’s a coverage issue by the time the patient arrives. That avoids billing delays and last-minute scrambles.

Having clear pricing info on vaccines, tests, and procedures also lets your staff answer cost-related questions confidently.

Stronger Coordination Between Teams

Too often, billing and front-desk teams work in silos. That can lead to miscommunication and repeated errors.

Better billing systems close the loop. For example, your billing team might flag:

• “We’re getting denials due to outdated insurance.”
  Sharing that with the front desk prompts better intake protocols.

A monthly check-in between billing and front-desk leads can keep everyone aligned.
(At Altus, we include front-desk coaching to help practices bridge this gap and reduce repeat issues.)

Higher Patient Satisfaction

When the front desk runs smoothly, patients notice. They appreciate being told upfront what’s owed and why—rather than receiving a confusing bill later.

It’s much better for a receptionist to say:

• “Your insurance requires a $30 copay today—does that sound right?”
  than for a parent to get a surprise bill three weeks later.

Accurate billing supports positive patient relationships and trust in your practice.

Less Stress for Your Front Desk Team

Your front-desk staff already juggle phones, walk-ins, paperwork, and scheduling. Add billing issues on top, and burnout becomes real.

Smart billing systems can automate statements, enable online bill pay, and reduce billing-related calls. Some practices even route billing questions directly to a dedicated staff member or outsourced team.

Reducing this workload creates a calmer, more productive front desk.

Empowered Financial Conversations

In pediatric practices, it’s often the front desk—not the provider—who has financial discussions with families.

A strong billing program provides tools, policies, and scripts to support these conversations.

For example:

• “If a patient can’t pay in full, collect $X and set up a payment plan.”

Consistency is key—every parent should get the same message. With training and the right resources, your staff can communicate clearly and compassionately.

At Altus, we work closely with practices to provide these tools and serve as a behind-the-scenes resource for your staff.

Practical Tips to Integrate Billing and Front-Desk Workflows

• Create a billing checklist for the front desk (verify insurance, collect copay, check balances, confirm address).

• Use system alerts to prompt staff: “Collect $50 copay” or “Balance overdue.”

• Give access to billing notes or provide a quick contact path to your billing team.

• Cross-train staff so both billing and front-desk teams understand each other’s workflows.

The Takeaway

A smoother front desk means a better experience for patients—and a better workday for your team. Improving billing isn’t just about revenue. It’s about removing roadblocks from your operations.

By investing in smarter billing systems and tighter communication, your front office becomes a more effective, confident part of the revenue cycle.

Stay tuned for our upcoming post: “Front Desk and Billing: Working in Sync for Pediatrics,” featuring checklists, scripts, and more ways to streamline your workflows.

Is Your Fee Schedule Costing You Money? How to Find Out

When was the last time you reviewed your practice’s fee schedule? Many pediatric practices set their fees years ago and only adjust when absolutely necessary. However, an outdated or suboptimal fee schedule can quietly erode your revenue year after year. In simple terms, your fee schedule is the list of prices you charge for each service (office visits, immunizations, procedures, etc.). It might seem like just a formality, especially if you’re in-network with insurers (since they have contracted rates), but it plays a crucial role in how much revenue you generate. Let’s discuss why an improper fee schedule can cost you, and how to evaluate and optimize yours.

How your fee schedule affects revenue: For insurance payers you contract with, you typically agree to accept their allowed amount as full payment. If your charge is higher than the allowed amount, you write off the difference (contractual adjustment). If your charge is equal to or lower than the allowed amount, the insurer will just pay your charge amount (since they won’t pay more than you billed). In that latter case, you effectively lose money because you could have been paid more if you had charged more. For out-of-network services or self-pay patients, your fee schedule directly determines what you collect (subject to any discounts or negotiations). So, two big pitfalls are: charging below what insurers are willing to pay, and not reflecting your practice’s value/costs in your prices.

Consider an example: Suppose Medicaid allows $100 for a certain pediatric service, and a commercial payer allows $120. If your fee for that service is $80 (perhaps set long ago), then even the commercial payer will only pay $80 (instead of $120), because you billed $80. You just lost $40 of potential revenue on that service, and maybe you thought you were doing fine because you got “100% of what you billed.” This can give a false sense of success – collecting 100% of a low charge is worse than collecting 67% of a much higher charge. As one source notes, if you’re charging less than Medicare (or market) allows, you may feel prosperous since all your claims pay at 100%, but in reality, you’re underbilling. Many practices simply don’t know they’re undercharging. In fact, studies have found that unfortunately many practices are losing revenue because of their fee schedule and don’t realize updating it would improve their bottom line​.

Signs your fee schedule might be costing you money:

• You’re receiving insurance payments where the paid amount equals exactly what you charged (with no contractual write-off). This means your charge was at or below the insurer’s allowance – money left on the table.

• You haven’t updated your fees in over a year or two. Medical costs and insurer allowances tend to increase (modestly) over time; if your fees are stagnant, they may fall below current allowable amounts.

• Different services in your practice have inconsistent markups. Perhaps some codes you set at 100% of Medicare rates, others at 150%, others arbitrarily. This could cause some to be underallowed.

• Your practice has added new services (e.g., telemedicine visits, new vaccine codes, developmental testing) but you just guessed fees for them or copied Medicare rates without considering if commercial payers pay more.

• You find that for certain codes, you never have a write-off adjustment on EOBs (a clue that your charge is likely under the insurance’s allowable).

So how do you find out and fix it? Perform a fee schedule analysis:

1. Compare your fees to payer allowables: For your top 20-30 most frequently used CPT codes, make a chart of your current fee vs. what the major payers allow for that code. You can get payer allowable info from contract sheets or from analyzing EOBs (the difference between what you billed and the adjustment is the allowed amount). Pay special attention to Medicare (or your state Medicaid) as a baseline, since many private plans base their rates on Medicare. If you discover, for example, you charge $75 for code X, Medicare allows $80, and Blue Cross allows $90, you know you’re undercharging by a lot. 
   1. Rule of thumb: Your fee should be at least as high as the highest typical allowable among your major payers, if not more. In pediatrics, Medicare fees might not always be directly applicable (since Medicare covers pediatricians only for certain services like vaccines via Medicaid or if you see older adolescents), but private plans often peg to Medicare rates (e.g., 110% of Medicare). The AAP and practice management experts often recommend setting pediatric fees at 125%–150% of Medicare rates for physician services​, to ensure you’re above most insurance allowables and account for pediatric-specific factors. So if Medicare is $100 for a code, your charge might be $125 or $150. This usually safely exceeds what any private payer will allow, meaning you’ll capture the full payable amount from all of them.

2. Examine patterns on EOBs/ERA: Look at a few remittance advice documents. If you consistently see “Provider write-off: $0.00” on an insurance payment, that’s a sign your charge was at or below their allowed. Ideally, you want to see a write-off on most in-network insurance payments – that indicates you charged above their allowed and they paid in full per contract (with you writing off the rest). For example, if you billed $150, allowed $120, paid $120, write-off $30 – that’s good (you got the max $120). If you see billed $100, allowed $120, paid $100, write-off $0 – that’s bad (you could have gotten $20 more had you billed higher). Do this check for high-volume codes like well-visit codes (99391-99395 etc.), common sick visit codes (99213, 99214), and procedures (90460 immunization admin, 92551 hearing screen, etc.). If any of those show no adjustments, mark them as underpriced.

3. Consider your payer mix and specific contract terms: Some practices intentionally keep fees low for certain payers (like Medicaid, which might not pay above their fee schedule anyway). But note: even Medicaid will pay up to their max. If your fee is below Medicaid’s fee schedule, you’re losing out on those few extra dollars per service that Medicaid would have paid. It might seem minor, but across thousands of Medicaid visits, it counts up, and there’s no benefit to charging less than Medicaid allows. For commercial payers, also factor in things like carve-outs: e.g., vaccines might be paid at vaccine cost plus admin – but your charge still matters for the admin part or any percent-of-charge calculations. Some payer contracts (like certain capitated or percent-of-charge agreements) could complicate this, but most pediatricians are on fee-for-service contracts these days.

4. Adjust your fees strategically: If you identify that many of your fees are below allowables, it’s time to update the fee schedule. Best practice is to review (and if needed, update) fees at least annually​. Semi-annually is even better, because things change (e.g., CPT code valuations, vaccine costs) and you want to keep pace. When raising fees, avoid extremely steep increases all at once for patient-facing charges – you might consider phasing changes or communicating if something big changes. However, for many codes, an increase will mainly affect insurance payments. For example, raising your E&M visit fees from $100 to $130 might not mean patients pay more (their copay stays the same), but insurance will now pay you more (up to their allowed). One caution: if you’re out-of-network for some patients, they could be balance-billed the higher amount; consider fairness there. Also, don’t set fees absurdly high without reason; some practices think they should charge, say, 300% of Medicare across the board. That can backfire if you ever have self-pay patients (leading to very high bills and possibly bad debt) or if regulators/payers scrutinize charges for reasonableness. Aim for a consistent, data-driven approach – e.g., 130% of Medicare for office visits, 150% for procedures, etc., or simply slightly above the highest payer allowable you have on file.

5. Review your vaccine and injectable fees: This is a pediatric-specific concern. Vaccines have their own cost (which fluctuates) and administration fees. You should ensure your vaccine product charges are updated to at least cover the cost (plus some margin if allowed by payers). Many vaccines are provided through VFC for those who qualify, but for private stock, if you bill less than your cost, you lose money. Check the current CDC vaccine private sector prices versus your charges. Administration fees: many insurers pay a set amount (often tied to Medicare rates for immunization admin CPT codes). Set your admin fee charges above the highest payer’s payment. Also consider things like synagis (if you administer it) or other pricey injectables – your charge should reflect acquisition cost and handling.

6. Assess if your fee schedule reflects your practice’s value: This is more qualitative, but think about where you might be undervaluing services. For instance, if you do extended consultations (like a 60-minute consult for ADHD or behavioral issues), are you charging appropriately for that time (perhaps using consult codes or prolonged service codes)? If not, adjust fees or coding practices so that you’re not essentially giving away services for free. Another example: forms or ancillary services. Some practices charge for extensive form completions or extra services not covered by insurance. Ensure those fees (if you have them) are in line with your costs and time.

7. Don’t forget to communicate changes when needed: Most fee schedule changes in-network don’t need to be communicated to patients because insurance contracts govern patient costs (copays, etc.). However, if you significantly raise self-pay rates or any membership fees (if you have a direct primary care element or similar), let families know in advance. Transparency is important to avoid confusion. For instance, some practices post a notice at the front desk annually like “Our fees are updated as of Jan 1 each year to ensure they remain current with industry standards; please ask if you have any questions.”

8. Leverage experts if needed: If analyzing a fee schedule sounds daunting, note that many medical billing services or consultants offer fee schedule reviews. They can benchmark your fees against regional data or specialty data. 
   1. (Altus performs a quarterly analysis of fee schedules and contract rates for our clients​ – meaning we regularly check if our client is charging appropriately and advise if certain codes should be increased. We essentially ensure our clients “set their pricing strategy” right, collaborating with them on it​.) 
   2. This kind of analysis can identify hidden gaps. Additionally, if you find that one payer’s allowables are very low (like below Medicare for many things), you might even consider renegotiating that contract or deciding if it’s worth staying in-network for that payer, but that’s a larger business decision.

In short, updating your fee schedule is one of the easiest levers to pull to increase revenue without seeing more patients or doing more work. It’s about getting paid fully for the work you’re already doing. Imagine you find 10 common services where you were undercharging by $10 each – and you perform each of those, say, 100 times a year. That’s $10 x 10 x 100 = $10,000 per year of revenue you could gain just by a fee tweak, with no change in service volume. For many practices, the gains are even higher.

Regular attention to your fee schedule ensures you’re not the proverbial frog slowly boiling in water – losing a bit of money each year due to stagnant fees without noticing until it’s a large amount. Instead, you stay proactive and keep your revenue at its potential. Your practice incurs costs (staff salaries, medical supplies) that rise with inflation, so should your fees.

Thrive with Proactive Billing and Expert Support

Pediatricians give their all to patient care—your billing process should reinforce that commitment, not work against it. As you’ve seen throughout this guide, optimizing your revenue cycle isn’t about bureaucracy or micromanaging every claim. It’s about building a financially healthy, sustainable practice that supports your team, grows with your goals, and delivers exceptional care to families.

We’ve covered a lot of ground:

• Preventing costly billing mistakes

• Tracking the right metrics

• Managing denials effectively

• Supporting front-desk efficiency

• And fine-tuning your fee schedule for long-term success

All of these components contribute to a streamlined, proactive revenue cycle that empowers your practice.

Take Control with Proactive Processes

Just as you focus on prevention in pediatric care, the same mindset applies to your billing. Small changes—like a monthly billing review, a structured denial follow-up process, or an annual fee schedule audit—can yield major gains in both revenue and time saved.

The key is staying ahead of problems, not reacting to them.

You Don’t Have to Do It Alone

If billing has become a source of stress or uncertainty in your practice, you’re not alone—and you’re not stuck. Many pediatricians eventually outgrow their current systems or billing partners and realize they need more specialized support.

At Altus Pediatric Billing, we work exclusively with pediatric practices. We offer comprehensive services designed to prevent errors, accelerate collections, and give your team real-time visibility into every aspect of the billing process. Our team is meticulous, tech-savvy, and deeply familiar with the nuances of pediatric coding and reimbursement.

We’re not just a vendor—we’re a partner who works hand-in-hand with your staff to improve processes and performance from the front desk to the final payment.

Trust Your Gut—and Take the Next Step

If your A/R is rising, if denials are piling up, or if you’re constantly fixing unpaid claims, don’t ignore those signs. If your current billing service isn’t meeting your expectations, you’re right to look for a better fit. That’s exactly why we created Altus—to offer the kind of expert, pediatric-specific billing support most practices don’t get elsewhere.

We invite you to learn more about our approach, explore our services, and meet the dedicated people who will support your success.

Start Improving Your Billing Today

Here’s how to begin:

• Identify 2–3 areas from this guide where your practice could improve

• Take small, focused actions—like updating processes, running an audit, or holding a denial review meeting

• Measure your progress, and refine from there

And if you’re ready for expert help, contact us for a free consultation. We’ll assess your current billing health and help you identify quick wins and long-term improvements.

At Altus Pediatric Billing, we make it our mission to ensure nothing slips through the cracks—and every service is paid for. With better billing comes less stress, stronger financial performance, and more time to focus on what you do best: caring for kids.

Your practice deserves to thrive. Let us help you get there.